• Reducing deaths among drug misusers ~ (March 31 2001 editorial published in British Medical Journal)
  • General Medical Council may be destroying the British System ~ Arnold's Response
    • The current state of dependency management in the UK ~ Dr. Byrne responds to Arnold
      • Your letter raises many important issues ~ Arnold responds to Dr. Byrne
  • Standard of care in Britain was not addressed ~ Andrew Byrne's Response
• Authors' Reply

EDITOR, Despite criticising American treatment practices, the editorial by Gabbay et al does not address the standard of care in Britain.¹ The United Kingdom reportedly has the highest death rates from opioids in Europe, at 22 per million,² and a proportion of these are from methadone.³

Other European countries have reported substantial decreases in such fatalities in the 1990s. Most have used both carefully prescribed opioids as well as other public health measures.2 It is unwise to prescribe unsupervised supplies of a strong medicine to unstable addicted patients. Doses may be taken early, they may be injected, or they may be used by others because of theft or on-selling. Most published addiction outcome studies have employed supervised dosing. With increasing stability, less frequent attendance is necessary and more flexibility possible. Despite widespread circulation of the British dependency guidelines,⁴ self regulation has apparently failed to encourage British doctors to follow the advice on supervision and dose levels. To avoid cravings, most dependent patients require 60-120 mg methadone daily.⁴ Initial doses, however, should not be higher than 40 mg, with prompt increases after careful assessments in the following days to avoid treatment dropouts. Inadequate dose levels, a lack of supervision, and poor access to treatment can all restrict treatment outcomes.

Such deficiencies in the United Kingdom may have sabotaged a potentially positive public health achievement. This could yet be attained, utilising the twofold British attributes of the profession's freedom to prescribe and universal access to treatment under the NHS. Although clinic induction is ideal for severely dependent patients, it is possible that general practitioners, with adequate support, can implement such treatment successfully, as practised in Scotland for over a decade.⁵ After stabilisation, any sympathetic, knowledgeable general practitioners should be able to manage patients having methadone maintenance treatment by using community pharmacies and established professional support systems. In rejecting government interference for dependency management, these authors confuse evidence based treatment (for example, methadone maintenance) with the practice of continuing to prescribe to known addicts under harm reduction principles (as for benzodiazepines, stimulants, and perhaps cocaine). Some have termed this "the British system," although this ambiguous term should be discarded.

As with heart disease, diabetes, or depression, patients with dependency deserve a careful history and physical examination plus special tests if required. Predictably, favourable outcomes should follow judicious prescribing when necessary, with appropriate safeguards and psychosocial supports. The threat of licensing should encourage British doctors to re-establish themselves as providers of best practice in the field of addiction as they have long done in other fields.

Andrew Byrne, general practitioner. Drug and Alcohol, 75 Redfern Street, Redfern, New South Wales 2016, Australia ajbyrne@ozemail.com.au

Competing interests: AB makes a proportion of his income from treating addiction and pain management patients.